Hospital Emergency Departments:

Crowded Conditions Vary among Hospitals and Communities

GAO-03-460: Published: Mar 14, 2003. Publicly Released: Mar 28, 2003.

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Hospital emergency departments are a major part of the nation's health care safety net. Emergency departments report being under increasing pressure, with the number of visits nationwide increasing from an estimated 95 million in 1997 to an estimated 108 million in 2000. GAO was asked to provide information on emergency department crowding, including the extent hospitals located in metropolitan areas are experiencing crowding, the factors contributing to crowding, and the actions hospitals and communities have taken to address crowding. To conduct this work, GAO surveyed over 2,000 hospitals and about 74 percent responded. The survey collected information on crowding, such as data on diversion--that is, the extent to which hospitals asked ambulances that would normally bring patients to their hospitals to go instead to other hospitals that were presumably less crowded.

While many emergency departments across the country reported some degree of crowding, the problem is more pronounced in certain hospitals and communities. For example, while 2 of every 3 hospitals reported asking ambulances to be diverted to other hospitals at some point in fiscal year 2001, a smaller portion--about 1 of every 10--reported being on diversion status for more than 20 percent of the year. Hospitals in areas with larger populations, areas with high population growth in recent years, and areas with higher-than-average percentages of people without health insurance reported higher levels of crowding. While no single factor stands out as the reason why crowding occurs, GAO found the factor most commonly associated with crowding was the inability to transfer emergency patients to inpatient beds once a decision had been made to admit them as hospital patients rather than to treat and release them. When patients "board" in the emergency department due to the inability to transfer them elsewhere, the space, staff, and other resources available to treat new emergency patients are diminished. Hospitals and communities reported a variety of actions to address crowding, including expanding their emergency departments and developing ways to transfer emergency patients to inpatient beds more efficiently. For the most part, these actions have not been extensively evaluated, so their effect is unknown. However, the widely varying characteristics between hospitals mean that no one approach is likely to emerge as a way to address this ongoing concern. Representatives from the American College of Emergency Physicians and the American Hospital Association and an independent reviewer provided comments on a draft of this report, which we incorporated as appropriate.

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